Diagnostic Evaluation of Pediatric Hypertension

  • Joyce P. SamuelEmail author
  • Rita D. Swinford
  • Ronald J. Portman
Reference work entry


The management of hypertension in the pediatric population begins with a thorough diagnostic evaluation which can be tailored to the individual patient based on age, symptoms, and severity of hypertension. We outline four phases of evaluation which are integral to the optimal management of hypertension in children. Phase 1 seeks to determine whether the patient is truly hypertensive in the nonmedical setting. This can be accomplished with either ambulatory blood pressure monitoring or self-monitored (home) blood pressure monitoring. Once hypertension is confirmed, the Phase 2 provides the initial screening for potential etiologies, hypertensive end-organ damage, and comorbidities. Phase 3 of evaluation further defines any abnormality identified during screening, and the Phase 4 determines the significance and remediability of the abnormality. By systematically using the four phases outlined in this chapter, the clinician can conduct a comprehensive yet thoughtful evaluation of the hypertensive patient.


Secondary hypertension Diagnosis Evaluation Etiology 


  1. Alpert BS, Bain HH, Balfe JW, Kidd BS, Olley PM (1979) Role of the renin-angiotensin-aldosterone system in hypertensive children with coarctation of the aorta. Am J Cardiol 43:828–834CrossRefGoogle Scholar
  2. Becker AE, Becker MJ, Edwards JE (1970) Anomalies associated with coarctation of aorta: particular reference to infancy. Circulation 41:1067–1075CrossRefGoogle Scholar
  3. Bratincsak A, Williams M, Kimata C, Perry JC (2015) The electrocardiogram is a poor diagnostic tool to detect left ventricular hypertrophy in children: a comparison with echocardiographic assessment of left ventricular mass. Congenit Heart Dis 10:E164–E171CrossRefGoogle Scholar
  4. Brun P, Kchouk H, Mouchet B, Baudouin V, Raynaud A, Loirat C, Azancot-Benisty A (1997) Value of Doppler ultrasound for the diagnosis of renal artery stenosis in children. Pediatr Nephrol 11:27–30CrossRefGoogle Scholar
  5. Dionne JM, Turik MM, Hurley RM (2008) Blood pressure abnormalities in children with chronic kidney disease. Blood Press Monit 13:205–209CrossRefGoogle Scholar
  6. Dursun H, Bayazit AK, Cengiz N, Seydaoglu G, Buyukcelik M, Soran M, Noyan A, Anarat A (2007) Ambulatory blood pressure monitoring and renal functions in children with a solitary kidney. Pediatr Nephrol 22:559–564CrossRefGoogle Scholar
  7. Eguchi K, Pickering TG, Hoshide S, Ishikawa J, Ishikawa S, Schwartz JE, Shimada K, Kario K (2008) Ambulatory blood pressure is a better marker than clinic blood pressure in predicting cardiovascular events in patients with/without type 2 diabetes. Am J Hypertens 21:443–450CrossRefGoogle Scholar
  8. Flynn JT (2002) Differentiation between primary and secondary hypertension in children using ambulatory blood pressure monitoring. Pediatrics 110:89–93CrossRefGoogle Scholar
  9. Flynn J, Zhang Y, Solar-Yohay S, Shi V (2012) Clinical and demographic characteristics of children with hypertension. Hypertension 60:1047–1054CrossRefGoogle Scholar
  10. Flynn JT, Daniels SR, Hayman LL et al (2014) Update: ambulatory blood pressure monitoring in children and adolescents: a scientific statement from the American Heart Association. Hypertension 63:1116–1135CrossRefGoogle Scholar
  11. Flynn JT, Kaelber DC, Baker-Smith CM et al (2017) Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics 140(3):e20171904Google Scholar
  12. Glushien AS, Mansuy MM, Littman DS (1953) Pheochromocytoma; its relationship to the neurocutaneous syndromes. Am J Med 14:318–327CrossRefGoogle Scholar
  13. Havekes B, Romijn JA, Eisenhofer G, Adams K, Pacak K (2009) Update on pediatric pheochromocytoma. Pediatr Nephrol 24:943–950CrossRefGoogle Scholar
  14. Hermida RC, Smolensky MH, Ayala DE, Portaluppi F, Crespo JJ, Fabbian F, Haus E, Manfredini R, Mojon A, Moya A, Pineiro L, Rios MT, Otero A, Balan H, Fernandez JR (2013) 2013 ambulatory blood pressure monitoring recommendations for the diagnosis of adult hypertension, assessment of cardiovascular and other hypertension-associated risk, and attainment of therapeutic goals (summary). Joint recommendations from the International Society for Chronobiology (ISC), American Association of Medical Chronobiology and Chronotherapeutics (AAMCC), Spanish Society of Applied Chronobiology, Chronotherapy, and Vascular Risk (SECAC), Spanish Society of Atherosclerosis (SEA), and Romanian Society of Internal Medicine (RSIM). Clin Investig Arterioscler 25:74–82PubMedGoogle Scholar
  15. Khoury PR, Mitsnefes M, Daniels SR, Kimball TR (2009) Age-specific reference intervals for indexed left ventricular mass in children. J Am Soc Echocardiogr 22:709–714CrossRefGoogle Scholar
  16. Lande MB, Carson NL, Roy J, Meagher CC (2006) Effects of childhood primary hypertension on carotid intima media thickness: a matched controlled study. Hypertension 48:40–44CrossRefGoogle Scholar
  17. Lurbe E, Alvarez V, Redon J (2001) Obesity, body fat distribution, and ambulatory blood pressure in children and adolescents. J Clin Hypertens (Greenwich) 3:362–367CrossRefGoogle Scholar
  18. Lurbe E, Redon J, Kesani A, Pascual JM, Tacons J, Alvarez V, Batlle D (2002) Increase in nocturnal blood pressure and progression to microalbuminuria in type 1 diabetes. N Engl J Med 347(11):797–805CrossRefGoogle Scholar
  19. Martinez-Aguayo A, Fardella C (2009) Genetics of hypertensive syndrome. Horm Res 71:253–259Google Scholar
  20. May AL, Kuklina EV, Yoon PW (2012) Prevalence of cardiovascular disease risk factors among US adolescents, 1999–2008. Pediatrics 129:1035–1041CrossRefGoogle Scholar
  21. Mcniece KL, Gupta-Malhotra M, Samuels J, Bell C, Garcia K, Poffenbarger T, Sorof JM, Portman RJ, National High Blood Pressure Education Program Working, G (2007) Left ventricular hypertrophy in hypertensive adolescents: analysis of risk by 2004 National High Blood Pressure Education Program Working Group staging criteria. Hypertension 50:392–395CrossRefGoogle Scholar
  22. Meyers KE, Cahill AM, Sethna C (2014) Interventions for pediatric renovascular hypertension. Curr Hypertens Rep 16:422CrossRefGoogle Scholar
  23. Mitchell P, Cheung N, De Haseth K, Taylor B, Rochtchina E, Islam FM, Wang JJ, Saw SM, Wong TY (2007) Blood pressure and retinal arteriolar narrowing in children. Hypertension 49:1156–1162CrossRefGoogle Scholar
  24. Mitsnefes M, Flynn J, Cohn S, Samuels J, Blydt-Hansen T, Saland J, Kimball T, Furth S, Warady B, Group, C. K. S (2010) Masked hypertension associates with left ventricular hypertrophy in children with CKD. J Am Soc Nephrol 21:137–144CrossRefGoogle Scholar
  25. NHBPEP (2004) The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics 114:555–576CrossRefGoogle Scholar
  26. Olin JW, Piedmonte MR, Young JR, Deanna S, Grubb M, Childs MB (1995) The utility of duplex ultrasound scanning of the renal arteries for diagnosing significant renal artery stenosis. Ann Intern Med 122:833–838CrossRefGoogle Scholar
  27. Pall D, Juhasz M, Lengyel S, Molnar C, Paragh G, Fulesdi B, Katona E (2010) Assessment of target-organ damage in adolescent white-coat and sustained hypertensives. J Hypertens 28:2139–2144CrossRefGoogle Scholar
  28. Patzer L, Seeman T, Luck C, Wuhl E, Janda J, Misselwitz J (2003) Day- and night-time blood pressure elevation in children with higher grades of renal scarring. J Pediatr 142:117–122CrossRefGoogle Scholar
  29. Prineas RJ, Ostchega Y, Carroll M, Dillon C, Mcdowell M (2007) US demographic trends in mid-arm circumference and recommended blood pressure cuffs for children and adolescents: data from the National Health and Nutrition Examination Survey 1988–2004. Blood Press Monit 12:75–80CrossRefGoogle Scholar
  30. Schwartz GJ, Munoz A, Schneider MF, Mak RH, Kaskel F, Warady BA, Furth SL (2009) New equations to estimate GFR in children with CKD. J Am Soc Nephrol 20:629–637CrossRefGoogle Scholar
  31. Seeman T, Palyzova D, Dusek J, Janda J (2005) Reduced nocturnal blood pressure dip and sustained nighttime hypertension are specific markers of secondary hypertension. J Pediatr 147:366–371CrossRefGoogle Scholar
  32. Sorof JM, Cardwell G, Franco K, Portman RJ (2002) Ambulatory blood pressure and left ventricular mass index in hypertensive children. Hypertension 39:903–908CrossRefGoogle Scholar
  33. Steinberger J, Daniels SR, Hagberg N, Isasi CR, Kelly AS, Lloyd-Jones D, Pate RR, Pratt C, Shay CM, Towbin JA, Urbina E, Van Horn LV, Zachariah JP, American Heart Association Atherosclerosis, H, Obesity in the Young Committee of the Council on Cardiovascular Disease in the, Y, Council on, C, Stroke N, Council on, E, Prevention, Council on Functional, G, Translational, B, Stroke, C (2016) Cardiovascular health promotion in children: challenges and opportunities for 2020 and beyond: a scientific statement from the American Heart Association. Circulation 134:E236–E255CrossRefGoogle Scholar
  34. Stergiou GS, Giovas PP, Kollias A, Rarra VC, Papagiannis J, Georgakopoulos D, Vazeou A (2011) Relationship of home blood pressure with target-organ damage in children and adolescents. Hypertens Res 34:640–644CrossRefGoogle Scholar
  35. Toka HR, Luft FC (2002) Monogenic forms of human hypertension. Semin Nephrol 22:81–88CrossRefGoogle Scholar
  36. Valent-Moric B, Zigman T, Zaja-Franulovic O, Malenica M, Cuk M (2012) The importance of ambulatory blood pressure monitoring in children and adolescents. Acta Clin Croat 51:59–64PubMedGoogle Scholar
  37. Vehaskari VM (2009) Heritable forms of hypertension. Pediatr Nephrol 24(10):1929–1937CrossRefGoogle Scholar
  38. Wiggelinkhuizen J, Cremin BJ (1978) Takayasu arteritis and renovascular hypertension in childhood. Pediatrics 62:209–217PubMedGoogle Scholar
  39. Williams KM, Shah AN, Morrison D, Sinha MD (2013) Hypertensive retinopathy in severely hypertensive children: demographic, clinical, and ophthalmoscopic findings from a 30-year British cohort. J Pediatr Ophthalmol Strabismus 50:222–228CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG 2018

Authors and Affiliations

  • Joyce P. Samuel
    • 1
    Email author
  • Rita D. Swinford
    • 1
  • Ronald J. Portman
    • 2
  1. 1.Division of Pediatric Nephrology and HypertensionMcGovern Medical School, University of Texas Health Science Center at HoustonHoustonUSA
  2. 2.Pediatric Therapeutic AreaNovartis Pharmaceuticals CorporationEast HanoverUSA

Section editors and affiliations

  • Karen M. Redwine
    • 1
  1. 1.Department of Pediatrics, Arkansas Children's HospitalUniversity of Arkansas for Medical SciencesLittle RockUSA

Personalised recommendations